A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 minutes, last 90 seconds each, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction, nadir after the peak of the contraction, and a return to baseline after the contraction is over.
Which of the following actions should the nurse take?
Increase the rate of infusion of the IV oxytocin.
Decrease the rate of infusion of the maintenance IV solution.
Discontinue the infusion of the IV oxytocin.
Slow the client's rate of breathing.
Slow the client's rate of breathing.
The Correct Answer is C
Choice A rationale
Increasing the rate of infusion of IV oxytocin in the presence of abnormal fetal heart rate decelerations is contraindicated. It may exacerbate uterine hyperstimulation, further compromising fetal oxygenation.
Choice B rationale
Decreasing the rate of infusion of the maintenance IV solution will not address the issue of uterine hyperstimulation or abnormal fetal heart rate decelerations. The focus should be on managing oxytocin administration.
Choice C rationale
Discontinuing the infusion of IV oxytocin is appropriate due to uterine tachysystole and associated fetal heart rate decelerations. This helps reduce uterine contractions and allows for fetal recovery, improving oxygenation.
Choice D rationale
Slowing the client's rate of breathing is not related to managing uterine contractions or fetal heart rate decelerations. The intervention should directly address the cause of the decelerations, which is oxytocin-induced hyperstimulation. .
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Explanation
Choice A rationale
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Choice B rationale
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Choice C rationale
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Choice D rationale
Age less than 25 years is not a risk factor for breast cancer; risk increases with age.
Correct Answer is D
Explanation
Choice A rationale
Administering the rubella vaccine during pregnancy, including the third trimester, is contraindicated due to the risk of live vaccine transmission to the fetus. It is not recommended at any stage of pregnancy.
Choice B rationale
Advising the client to get the vaccine during her next pregnancy attempt is partly correct but lacks the immediacy needed to ensure she is immune before the next pregnancy. The vaccine should be given postpartum.
Choice C rationale
Administering the vaccine immediately during pregnancy is contraindicated due to potential risks to the fetus. Rubella vaccines contain live virus, which can cause fetal harm if given during pregnancy.
Choice D rationale
It is safest to administer the rubella vaccine postpartum, prior to hospital discharge, to ensure the client has immunity before any future pregnancies. This timing prevents any risk to the current fetus and ensures future fetal protection. .